TMA Wants Stronger Grace Period Notification

The Centers for Medicare & Medicaid Services (CMS) should require
insurers who offer health plans on the Affordable Care Act exchanges to provide
immediate notice when patients enter the first month of the 90-day grace period.
That's what the Texas Medical Association, the American Medical Association, and
more than 80 state medical societies and specialty organizations told CMS
Administrator Marilyn Tavenner in a letter.

The groups have asked CMS to revisit its policy that allows plans to pend and
deny claims for months two and three of the 90-day grace period, which begins
when patients fail to make a premium payment for a subsidized ACA marketplace
plan. "We further urge CMS to strengthen the requirements for how and when
issuers notify physicians and other providers that a patient who has purchased
subsidized … health insurance coverage has entered the 90-day grace period for
nonpayment of premiums," the letter states.

Physicians have voiced concern over federal rules that put them at risk of
health plans' clawing back any payments made in the second or third month of the
grace period when patients are delinquent on premium payments.

Under ACA, marketplace regulations give patients with subsidized health
insurance coverage three months to pay their premiums and allow health plans to
deny or later recoup payments from doctors for services provided to patients who
are delinquent. The patients must have paid at least their first month's premium
to be eligible for that 90-day grace period.

Federal regulations require exchange plans to notify affected physicians "as
soon as is practicable when an enrollee enters the grace period, since the risk
and burden are greatest on the provider." Notification includes where the
enrollee is in the grace period and the names of everyone covered by the policy.
The notice must tell doctors the health plan may ultimately deny payment. But
federal rules don't specify when or how insurers have to send the
notification.

TMA and other organizations call the notice requirements "inadequate" and say
they'll "lead to administrative confusion for physicians and practices." The
groups "urge CMS to require issuers to notify providers of a patient's grace
period status as part of the insurance eligibility verification process."

"CMS has unfairly shifted the burden and risk of potential loss for patient
non-payment of premiums to physicians," the letter states. "This financial
burden will be untenable for many physicians."

AMA plans to develop tools to help physicians navigate the complexities of
the ACA grace period.

TMA Presses SGR Repeal

In a letter to leaders of the U.S. House and Senate, TMA, the
American Medical Association, and more than 600 physician organizations
throughout the nation pressed for passage of legislation by March 31 to "repeal
the fatally flawed sustainable growth rate (SGR) formula." A 24-percent cut to
Medicare payments will occur April 1 if Congress fails to act.

HR 4015 and S 2000, known as the SGR Repeal and Medicare Provider Payment
Modernization Act of 2014, represent a bipartisan, bicameral agreement
"resulting from tireless efforts among the three key congressional committees of
jurisdiction to develop a solution for a problem that has bedeviled lawmakers
for years," the groups said.

Meanwhile, on Wednesday, TMA sent a letter to Texans in Congress. In the letter, TMA President
Stephen L. Brotherton, MD, reminds lawmakers in both chambers, "We’ve made it
this far only because of a bipartisan, bicameral agreement on the need to
replace the SGR."

"Crafting the appropriate health care policy precepts of the bill was the
hard part," he wrote. "Please don't stop here."

To date, Congress has enacted 16 SGR patches to the tune of $153.7 billion, a
total TMA and the organizations that signed on to the letter say far exceeds
what it would cost to reform the Medicare physician payment system once and for
all. The 10-year cost of HR 4015/S 2000 is $138 billion.

"We can no longer afford to spend taxpayer money on stopgap measures that
preserve a failed policy," the letter from the 600 medical associations
states.

The groups state in the letter that the Medicare Provider Payment
Modernization Act includes health care delivery and physician payment reform
recommendations from the physician community. It also calls for significant
resources and tools to help physicians transition to new payment and delivery
models.

The letter concludes by imploring Congress to "quickly seize the opportunity
to take advantage of this work and momentum to finally break the SGR status quo
and pass a long-term solution."

Attest by April 1 for Medicaid Primary Care Pay Increase

To qualify for the full Medicaid primary care physician payment increase
authorized by the Affordable Care Act, eligible physicians must submit an attestation form by April 1. Physicians who submit a
form before April 1 will be eligible for retroactive payments from Jan. 1, 2013.
Physicians who attest after the deadline will receive only retroactive payments
from the date Texas Medicaid & Healthcare Partnership (TMHP) received the
attestation.

If a physician's attestation has a postmark before the deadline, TMHP must
honor it, even if the form contains errors or omissions. TMHP has posted an
updated list of physicians who have successfully attested as of Feb.
18. Additionally, TMHP recently posted a list of Frequently Asked Questions and Answers regarding the
supplemental payments.

The health care reform law grants a rate increase for certain primary care
physicians and their services from Jan. 1, 2013, through Dec. 31, 2014. To
receive the higher payments, physicians must self-attest that they practice in
an eligible specialty and that either:

They are board certified in family medicine, general internal medicine,
pediatric medicine, or are a subspecialty within those designations as
recognized by the American Board of Medical Specialties, the American
Osteopathic Association, or the American Board of Physician Specialties, or

Sixty percent of their Medicaid billings for the prior year were for
eligible evaluation and management (E&M) services. Those eligible services
are E&M codes 99201 through 99499 and services related to the administration
of vaccines (90465, 90466, 90467, 90468, 90471, 90472, 90473, and 90474).

Physicians who submitted a form but are not on the list should contact the
TMHP call center at (800) 925-9126.

In March, Medicaid HMOs began paying supplemental payments to physicians who
had successfully attested by Oct. 16, 2013. Initial payments are for eligible
services provided in the first quarter of 2013.

For physicians who completed the attestation process between mid-October and
mid-February, HMOs will begin issuing retroactive supplemental payments in late
April. Once the initial supplemental payments have been made, HMOs will begin
issuing periodic payments for all remaining eligible services provided through
April 2014. Thereafter, payments will be made on a quarterly basis.

The interim payment schedule will vary by HMO, so please contact the plans
with which you contract for additional details. Please note that supplemental
payments don't currently include vaccine administration fees or Texas Health
Steps services billed by a group practice. Payments for those services must
still be calculated and will be paid at a later date.

If Texas Medicaid inaccurately calculated a claim or omitted a claim from
payment, please contact TMHP.

Medicare End-to-End Testing Accepting Volunteers

Ready to test ICD-10 with Medicare? The Centers for Medicare & Medicaid
Services (CMS) will select volunteer clearinghouses and physicians to
participate in end-to-end testing of ICD-10 the week of July 21-25. The deadline
to volunteer is March 24.

CMS will enlist more than 500 volunteer physicians, clearinghouses, and
providers nationwide for the testing. Novitas Solutions, like its sister
Medicare administrative contractors, will be allowed to select 32
physicians/providers from Jurisdiction H.

End-to-end testing encompasses submitting test claims to CMS with ICD-10
codes through receiving a remittance advice that explains the adjudication of
the claims — hopefully all successfully.

If you use a clearinghouse, encourage your vendor to volunteer for the
testing (you might even forward this notice). If you have the ability to submit
claims directly to Novitas and want to volunteer, complete the Volunteer Testing Form. You'll receive more information if you
are selected.

Find more information about testing at MLN Matters No. SE1409 Revised and about volunteering at
MLN Matters No. MM8602 from CMS.

If you have any questions, contact Novitas Solutions at (855) 252-8782.

TMA Releases 2nd Edition of NPP Guide

Last year, the Texas Legislature passed legislation that replaces site-based
requirements for the delegation and supervision of prescriptive authority for
nonphysician practitioners (NPPs) with a framework of delegation and supervision
that uses customizable prescriptive authority agreements.

To reflect these recent changes in legislation, TMA has released an updated
second edition of the best-selling publication Nonphysician Practitioners:
Hiring, Billing, and Delegation of Duties for a Nonphysician Practitioner.
The publication provides the most up-to-date, comprehensive information about
the qualifications, supervision requirements, and practical aspects of
contracting, credentialing, and billing for nonphysician practitioners. Click here to order the publication.

The prescribing of drugs and devices is a large part of the practice of
medicine. While you may delegate the prescribing and ordering of drugs or
devices to NPPs when appropriate, you must always supervise any delegation
appropriately in accordance with the standard of care.

Supreme Court to Review Antitrust Enforcement Case

The U.S. Supreme Court announced March 3 that it will decide whether a federal agency
can second-guess the work of state medical licensure boards.

The nation's highest court will hear North Carolina State Board of Dental
Examiners v. Federal Trade Commission (FTC), a case in which a
federal appeals court ruled in favor of the FTC's claim that state licensure
boards should be subject to antitrust laws. The appeals court's decision could
potentially strip these boards of their authority to regulate their health care
professions and shield patients from unlawful practice.

In a petition filed in late November, the Litigation Center of the
American Medical Association and State Medical Societies and other medical
groups urged the Supreme Court to consider the case. The petition argued that
"the public is best served when state regulatory boards … are free to make
decisions on public health issues without fear of second-guessing under the
federal antitrust laws."

AMA and other petitioners expressed concern over the case's "chilling effect"
on medical boards, as the FTC could use federal antitrust laws to second-guess
the board's actions on issues related to scope of practice and unlawful
practice.

Visit the AMA website for more information on the FTC's engagement with
state legislators and state boards of medicine. Read "Doctors Targeted" in the August 2012 issue of Texas
Medicine for more on the case.

Virtual ICD-10 Training in Your Office

With ICD-10 preparation well under way and the transition date less than
eight months away, it's time to determine how the new coding system will fit
into your practice's daily operations. How does your current documentation stack
up to the new guidelines, and what changes do your staff members need to make to
their standard workflow to ensure a seamless transition and steady payment flow?
Your practice's success is in the details.

TMA's new seminar, streaming live over the Internet March 18,
will train you and your staff in ICD-10 documentation and auditing. It will
cover navigating the expansive ICD-10 CM code book, the new coding guidelines,
and avoiding denied claims through proper documentation and audit methods.

The live streaming seminar gives you the opportunity to ask questions and
interact just as you would in person but without the travel. To register, visit
the TMA Education Center or call (877) 880-1335.

Rule Gives Patients Access to Lab Reports

Patients no longer have to call their physicians to get the results of a lab
test under a new federal rule that gives them direct access to the reports.

The Department of Health and Human Services (HHS) action amends earlier
federal requirements that patients access their lab tests through their
physicians. Patients can continue to do so, but the new flexibility "gives
patients a new option to obtain their test reports directly from the laboratory,
while maintaining strong protections for patients' privacy," HHS announced in
February.

Under certain circumstances, individuals designated by or personally
representing the patient also can see or obtain a copy of the patient's
protected health information, including an electronic copy.

The final regulation acknowledges concerns that a number of physicians and
laboratories expressed during rulemaking about giving patients a way to receive
laboratory test reports "without the benefit of provider interpretation and
without contextual knowledge that may be necessary to properly read and
understand the reports."

For example, physicians and labs cautioned that patients might receive and
act upon results that appear to be abnormal — such as showing false positives or
false negatives — or results that are out of the normal range for the general
population but may be normal for that particular patient due to his or her
medical conditions.

But HHS Secretary Kathleen Sebelius said "information like lab results can
empower patients to track their health progress, make decisions with their
health care professionals, and adhere to important treatment plans." Supporters,
such as consumer advocacy groups, agreed the change would give patients the
chance to play a more active role in their health care and have more informed
conversations with their health care professionals, resulting in better health
outcomes.

HHS officials pointed to studies showing physician practices sometimes fail
to inform patients of abnormal test results, "resulting in a substantial number
of patients not being informed by their providers of clinically significant
tests results." But those studies show that happens only about 7 percent of the
time.

Register for the Texas Health Home Summit Today

Join your colleagues for the second annual Texas Health Home Summit May 8-9 at the Westin Austin at The Domain to learn about medical home models
and best practices and to interact with experts at various stages of medical
home implementation. Register, and access fee information online.

Presented by the Texas Medical Home Initiative and the Texas Health
Institute, the event will focus on integration of behavioral health into the
health home and on health homes for children and adolescents. TMA is a sponsor
of the event and a planning committee member.

The summit encompasses:

An understanding of the medical home and how it promotes accessible,
continuous, and culturally effective health care.

Awareness of best practices to improve the medical home for all types of
patients.

Knowledge about how state and federal legislation impacts medical home
implementation.

Tools that can be used in the clinical practice or community to promote the
medical home.

A focus on consumer engagement and strengthened partnerships between
families, health professionals, and the health care system.

Continuing medical education credit information for the summit will be
announced soon.

TMA Knowledge Center Helps With Board Certification

Does your board certification process require journal articles? The TMA
Knowledge Center can help you by obtaining articles and performing custom
research requests.

Call the TMA Knowledge Center at (800) 880-7955, or send an email to get started.

Need a Cancer Expert? TMA Can Help

Are you looking for a speaker on the latest in cancer control and
prevention? The TMA Cancer Speakers Bureau is here to help.

The bureau, a TMA Committee on Cancer project, is made up of volunteer cancer
experts throughout Texas who can speak to physicians and other health care
professionals on:

Primary prevention and risk reduction;

Cancer screening and early detection;

Diagnosis, treatment, and palliation; and

Quality of life and survivorship.

If you're interested in another cancer-related topic, TMA can seek out
speakers to meet your needs. To request a speaker for your next event or
educational program, contact TMA at least 60 days in advance via email or by calling the TMA
Knowledge Center at (800) 880-7955.

March Madness Tips Off Hard Hats Giveaways

Spring is an ideal time to help Texas children be active and safe through
TMA's Hard Hats
for Little Heads bike helmet giveaway program. Sponsor a local giveaway in
2014 to help Hard Hats for Little Heads celebrate 20 years of keeping kids
safe.

TMA is running and gunning to give away its 200,000th helmet this year. The
goal: Give away 34,000 helmets. That's 10,000 more helmets than TMA usually
gives in a year. We need your help to make it happen.

Whether you see children in your practice or just want to keep kids safe, you
can give free helmets in your community. March, April, and May are three key
months to get in the game: Brain Injury Awareness Month, Texas Child Safety
Month, and Bike Month.

Hosting a giveaway is easy. TMA provides all you need — helmets and
promotional and educational materials. For the first 50 helmets you purchase,
TMA gives you another 50 helmets free. Helmets are $7.35 each, including
shipping.

Hard Hats for Little Heads is made possible through a grant from TMA
Foundation thanks to top donors — Blue Cross and Blue Shield of Texas,
Prudential, and two anonymous foundations — and generous gifts from physicians
and their families and friends of medicine.

This Month in Texas Medicine

The March issue of Texas
Medicine illustrates how financial forecasting leads to success in medical
practices. It also delves into continuing problems with Novitas,
UnitedHealthcare's termination of physicians from its Medicare Advantage plans,
patient satisfaction surveys, and results of a survey that gauges legislators'
perceptions of obesity-related topics..

Texas Medicine RSS Feed

Don't want to wait for Texas Medicine to land in your mailbox? You
can access it as an RSS feed, the
same way you get the TMA Practice E-Tips RSS feed.

E-Tips RSS Feed

TMAPractice E-Tips, a valuable source of hands-on,
use-it-now advice on coding, billing, payment, HIPAA compliance, office policies
and procedures, and practice marketing, is available as an RSS feed on
the TMA
website. Once there, you can download an RSS reader, such as Feedreader,
Sharpreader, Sage, or NetNewsWire Lite. You also can subscribe to the RSS feeds
for TMA news releases and for Blogged Arteries, the feed for
Action.

This Just In ...

Want the latest and hottest news from TMA in a hurry? Then log on to Blogged
Arteries.

Deadlines for Doctors

TMA's Deadlines for Doctors alerts you and your staff to upcoming
state and federal compliance timelines and offers information on key health
policy issues that impact your practice.

Action, the TMA newsletter, is emailed twice a month to bring you
timely news and information that affects your practice.

To change the email address where you receive Action, go to Member
Log-In on the TMA website, then click on "Update Your TMA Demographic
Information (including newsletter subscriptions and preferences)."

If you have any technical difficulties in reading or receiving this message,
please notify our managing editor, Shari
Henson. Please send any other comments or suggestions you may have about the
newsletter to Crystal Zuzek,
Action editor.